36C26318Q0499-004.docx

GUIDELINES FOR THE PREVENTION OF HEALTHCARE-ASSOCIATED LEGIONELLA DISEASE AND SCALD INJURY FROM POTABLE WATER DISTRIBUTION SYSTEMS

1. PURPOSE:

A. To provide guidelines for the detection and control of healthcare-associated Legionella disease in VHA-owned buildings in which patients, residents, or visitors stay overnight.

B. To establish procedures and responsibilities concerning hot water temperatures (scald control) and maintenance of water distribution systems at Fargo VA Health Care System (VAHCS).

2. POLICY: A multi-disciplinary Water Safety Committee will direct an ongoing program for healthcare-associated Legionella disease (HCA LD) prevention, including provisions necessary for the prevention of scald injury, in all VHA buildings in which patients, residents, or visitors stay overnight.

0. The Fargo VAHCS is at low risk for Legionella disease (LD) because of the following:

1) There have been zero (0) epidemiologically linked cases of Legionella disease at the Fargo VAHCS in the previous five (5) years. Epidemiologic surveillance data (from the North Dakota Department of Health) for the incidence of Legionellosis was evaluated for calendar year 2013. Overall Legionellosis remains an infrequent reportable disease in North Dakota with an overall yearly incidence of 0.41 cases per 100,000 North Dakota residents. Minnesota Department of Health epidemiologic surveillance data (for the Northwestern region) was also reviewed. Legionellosis remains a rare reportable disease in Northwestern Minnesota with an overall yearly incidence rate of zero (0) per 100,000 Northwestern Minnesota residents.

2) The Fargo VAHCS is not a transplant facility or a facility that cares for five (5) or more post transplant patients within three (3) months of surgery.

3) The Fargo VAHCS receives monochloramine treated water from the City of Fargo.

3. ACTION:

A. Responsibilities:

1) Health Care System Director. The Health Care System Director is responsible for:

a) Ensuring that the medical facility establishes a multi-disciplinary Facility Water Safety Committee.

b) Ensuring that the Fargo VAHCS has a written HCA LD prevention plan, including provisions necessary for the prevention of scald injury.

c) Approving and certifying annually the HCA LD prevention plan.

d) Submitting the facility HCA LD prevention plan, certification, and approval to the VISN Director.

e) Ensuring that the actions in the written HCA LD prevention plan(s) are implemented.

f) Ensuring that the medical facility has decommissioned all indoor, open decorative water features from all of its buildings, and future design plans do not include the installation of such indoor, open water features. NOTE: The use of indoor, open decorative water features has been epidemiologically-linked to LD in the healthcare setting.

g) Ensuring quarterly (at a minimum) environmental water testing is conducted for Legionella, and submits the results electronically to the VISN Director.

h) Providing annually to the VISN Director a summary of the medical facility’s clinical Legionella testing results and number of cases of LD (definite HCA LD, possible HCA LD, and community-associated LD).

i) Ensuring that all cases of LD are reported to the appropriate public health authority in accordance with applicable statutes, regulations, and with current VHA policy for infectious disease reporting, protecting health information, and release of information.

j) Requesting consultative assistance from the VHA Water Safety Program, through the VISN-level water safety liaison, on issues related to Legionella implementation of prevention efforts, if needed.

2) VHA Facility Chief of Staff (COS) and Associate Director of Patient Care Services. The VHA facility Chief of Staff and Associate Director of Patient Care Services are responsible for:

a) Ensuring that the medical facility has access to clinical care staff with expertise in infectious diseases to assist in diagnosis and treatment of LD. NOTE: Diagnostic testing of pneumonia patients for LD, especially when healthcare-association is suspected, can provide important information for surveillance and remediation purposes.

b) Ensuring that clinical staff involved in direct patient care are notified when cases of definite or possible HCA LD are identified to increase diagnostic awareness.

c) Ensuring that clinical staff involved in direct patient care are notified when routine environmental water testing is positive for Legionella pneumophila to increase diagnostic awareness.

3) VHA Facility Chief Engineer or Facility Manager. The VHA Facility Chief Engineer, Facility Manager, or equivalent is responsible for:

a) Ensuring that the maintenance of appropriate water temperatures in the hot and cold potable water distribution system(s) is in accordance with the facility’s approved HCA LD prevention plan(s).

b) Ensuring that digital thermometers are installed and maintained at each tub site for temperature verification.

c) Developing training components for competency and review for Engineering Service and plumbing staff on this policy.

d) Continuous monitoring of incoming water quality entering the Fargo VAHCS.

e) Conducting Infection Control Risk Assessments in cooperation with the Infection Control Coordinator.

f) Ensuring that newly installed piping and distribution system components are flushed of debris and disinfected prior to being placed into service.

g) Ensuring unused water branch lines and dead-legs are removed and capped at the main supply/recirculation supply lines to limit stagnation and reservoirs for Legionella growth.

h) Ensuring that only steam is used for building humidification purposes. Comply with prohibition of ultrasonic humidifiers, foggers, misters, spray humidifiers, and tank type humidifiers.

i) Ensuring Contracting assesses and documents competency of contractors and the contractor’s personnel as part of the acquisition process prior to the start of any work on facility water systems, including water treatment.

j) Ensuring competent personnel are available at all times to address water system operations.

k) Forwarding notification to all medical facility employees when:

(1) Maintenance and repair procedures will be taking place that could affect the water system;

(2) Maintenance and repair procedures have been completed; and,

(3) Affected systems have been tested and are returned to normal operation.

l) Providing the Facility Water Safety Committee, Environment of Care Committee, and Infection Control Committee with an annual report of the water system maintenance and monitoring and any Legionella mitigation actions taken.

4) VHA Facility Chief of Pathology and Laboratory Medicine. The VHA Facility Chief of Pathology and Laboratory Medicine Service is responsible for:

a) Ensuring that the laboratory has access to L. pneumophila urinary antigen testing.

b) Ensuring access to a clinical laboratory that can perform cultures on respiratory secretions for Legionella, with identification at the species level, and can determine the serogroup of L. pneumophila.

c) Ensuring that clinical cultures for Legionella and urinary antigen tests are performed in accordance with current VHA policy on laboratory testing.

d) Ensuring that results from laboratory tests and clinical cultures for Legionella are entered into the Computerized Patient Record System (CPRS) as soon as testing is completed.

e) Providing annually to the Infection Control Committee and the Facility Water Safety Committee the:

(1) Total number of urinary antigen tests and clinical cultures for Legionella ordered; and,

(2) Total number of persons with positive results for Legionella.

f) Ensuring that the Laboratory Service is involved in the process of selecting a laboratory that can perform environmental water and swab cultures for Legionella.

5) Facility Water Safety Committee Chair. The Facility Water Safety Committee Chair is responsible for:

a) Conducting an annual assessment to determine which buildings fall subject to VHA Directive 1061.

b) Developing a written HCA LD prevention plan for the Fargo VAHCS.

c) Reviewing the written HCA LD prevention plan(s) at least annually and updating as necessary.

d) Establishing the procedure for conducting environmental water testing for Legionella.

e) Conducting quarterly (at a minimum) meetings to review the records from implementation of the HCA LD prevention plan(s).

f) Ensuring the results of the reviews are communicated to the medical facility Leadership Team, Environment of Care Committee and Infection Control Committee.

6) Infection Control Coordinator (ICC). The Infection Control Coordinator is responsible for:

a) Reporting any HCA LD to the state health department.

b) Investigating any clinical case of HCA LD.

c) Promptly notifying the Chief of Staff, the Associate Director for Patient Care Services, and the Facility Water Safety Committee of any definite or possible HCA LD case in the facility.

d) Performing annual Legionella risk assessments in cooperation with Facility Chief Engineer or Facility Manager.

e) Entering facility Legionella clinical information into Inpatient Evaluation Center (IPEC).

7) Chief, Infectious Disease. The Chief, Infectious Disease, is responsible for:

a) Considering heightened awareness for clinical testing for HCA LD if L. pneumophila is found during environmental water testing or if a case of definite or possible HCA LD is detected in the facility.

8) Patient Safety Coordinator. The Patient Safety Coordinator is responsible for:

a) Maintaining documentation and follow-up of all patient incidents related to the furnishing of too high water temperatures (e.g., scalding).

9) Industrial Hygienist/Safety Manager. The Industrial Hygienist/Safety Manager is responsible for:

a) Ensuring environmental monitoring (via routine Environment of Care rounds) of all plumbed emergency equipment (i.e., showers, eye/face washes), including routine flushing to ensure proper working order and to prevent water stagnation.

b) Ensuring quarterly environmental water testing is performed in accordance with VHA Directive 1061.

10) Service Line (SL) Directors. Service Line Directors or designees are responsible for:

a) Ensuring that any problems encountered with the domestic hot or cold water systems are reported promptly to Engineering Service.

11) Patient Care Providers. Patient Care Providers are responsible for:

a) Water temperatures must be monitored and verified by comparing the digital readout on the tub with the temperature recorded by the temperature sensing probe that is submerged in the reservoir tank. These temperatures will be documented.

b) Submitting work orders to the Engineering Service if a device should fail to respond or the water temperature is excessive. This will be sent with a high priority request for immediate repair.

B. Procedure:

1) General Guidelines: Plumbing disruptions and water temperature influence the growth of microorganisms. Water borne pathogens have been associated with healthcare-associated urinary tract, blood stream, respiratory and other infections. The following will be utilized to prevent the growth of Legionella and other microorganisms in the hot water distribution system, in all patient care areas and to prevent scalding.

a. Water is obtained from the City of Fargo, which is monochlorinated.

b. Cold water will be maintained at or below 67 degrees Fahrenheit.

c. Semi-instantaneous hot water systems supply hot water to all patient care areas. These are not considered storage tanks. Water is constantly circulated through the jacket from the distribution system return loop. (Minimizes the likelihood of Legionella.)

d. Water temperature in hot water generator will be maintained to 130°F, with a maximum decrement in water temperature of 10°F at the tap, to reduce scalding hazards and conserve energy.

e. Thermostatic mixing valves, with built-in scald protection, will be installed on all outlets where water can be accessed from the potable hot water distribution system.

f. All patient baths at Fargo VAHCS are equipped with large readout devices displaying the water temperature. They are also equipped with elevated reservoir tanks. A remote temperature sensing probe has been submerged in the reservoir tank to provide for temperature verification. Maximum water temperature at the outlet will be 110°F.

g. Abandoned or inactive branch piping will be removed and capped off within four (4) inches of its junction with active supply lines to eliminate stagnation points in the hot water distribution system.

h. Regular flushing of hot and cold water at outlets (e.g., sink taps, showers), particularly those not in routine use or which experience low water flow, is necessary to ensure that engineering controls are maintained at sufficient levels for Legionella growth inhibition throughout the water distribution systems and at fixtures. See Prevention Plan for a specific listing of irregular use or low flow fixtures that will be flushed twice weekly by Engineering Maintenance and Repair personnel. EMS and Nursing personnel will flush toilets and sinks at random intervals in all patient and staff rooms.

i. Construction projects that affect or disrupt the water service will have an infection control risk assessment completed to address the potential impact of construction and maintenance of water systems on growth or transmission of waterborne pathogens and to determine the extent of precautions, disinfection, and system or component commissioning requirements. Any newly installed piping and distribution system components will be flushed of debris and disinfected prior to being placed into service for this building. Piping and components will be cleaned and protected from accumulation of debris and contamination prior to and during installation. Documentation of flushing and disinfection will be maintained by the Engineering Department.

j. Notification of patient care staff is required when maintenance is to be conducted that will cause disruption of the water distribution system, as well as when the maintenance is complete, and when the system is returned to normal operations. This will be accomplished via the use of email to all areas affected, or via an interfacility announcement (e.g., Code 2-Utilities Failure).

4. REFERENCES:

VHA Directive 1061, Prevention of Healthcare-Associated Legionella Disease and Scald Injury from Potable Hot Water Distribution Systems Circular EC-11, Utilities Management Plan American Society for Heating, Refrigerating and Air-conditioning Engineers (ASHRAE) Guideline 12-2000, Minimizing the Risk of Legionellosis Associated with Building Water Systems; 2000.

CDC Guidelines for Environmental Infection Control in Health-care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Morbidity and Mortality Weekly Reports (MMWR) 52 (RR10):1- 42; 2003. www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm CDC Guidelines for Preventing Healthcare-associated Pneumonia. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR 53(RR03):1-36; 2003. www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm Department of Veterans Affairs Office of Inspector General. Assessment of Legionnaires’ Disease Risk in Veterans Health Administration Inpatient Facilities. Report No. 07-00029-151, June 20, 2007. http://www.va.gov/oig/54/reports/VAOIG-07-00029-151.pdf.

Department of Veterans Affairs Office of Inspector General. Healthcare Inspection: Prevention of Legionnaires’ Disease in VHA Facilities. Report No. 13-01189-267; August 1, 2013. http://www.va.gov/oig/pubs/VAOIG-13-01189-267.pdf.

American Thoracic Society and Infectious Diseases Society of America. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated and Healthcare-associated Pneumonia. American Journal of Respiratory and Critical Care Medicine 171(4):388-416, 2005.

Association of Water Technologies. Legionella 2003: An Update and Statement by the Association of Water Technologies (AWT); June, 2003. http://awt.org/IndustryResources/Legionella03.pdf.

Department of Veterans Affairs, Veterans Health Administration, Executive Decision Memorandum. Indoor Decorative Water Features in VHA Healthcare Facilities. Approved November 26, 2012. http://vaww.nlc.portal.va.gov/EDMs/EDMDocuments/2012%20Approved%20Executive%20Decision%20Memos/EDM%20Indoor%20Decorative%20Water%20Features.pdf. NOTE: This is an internal VA Web site and is not available to the public.

Facilities Guidelines Institute. Guidelines for Design and Construction of Health Care Facilities, 2010 edition. Chicago: American Society of Healthcare Engineering of the American Hospital Association; 2010.

International Code Council. International Plumbing Code (IPC), Chapters 1 through 6 2009 IPC. International Code Council, Inc.; 2009.

Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 44:S27-72; 2007. l. Occupational Safety & Health Administration (OSHA). OSHA Technical Manual, Section III: Chapter 7. Legionnaire’s Disease. Effective date: January 20, 1999.

World Health Organization (WHO). Legionella and the Prevention of Legionellosis WHO Press, 2007. http://www.who.int/water_sanitation_health/emerging/legionella.pdf 40 CFR part141. National Primary Drinking Water Regulations.

40 CFR part142. National Primary Drinking Water Regulations Implementation

5. RESPONSIBILITY: Infection Control Coordinator (124) and Chief, Engineering (138) are responsible for the contents of this circular.

6. RESCISSION: Circular IC-25, dated December 27, 2012

7. REVIEW DATE: February 2018

Attachments:

ACTION PLAN FOR HEALTHCARE ASSOCIATED (HCA) LEGIONELLA

In the event of a HCA case of Legionella pneumonia, the Water Safety Committee will call to order an emergent meeting including:

· All Water Safety Committee Members

· Administration

· Clinicians from high-risk areas, including the area where the index case occurred

· Nursing Service

The following actions will be taken:

ATTACHMENT A

MITIGATION OF LEGIONELLA IN FACILITY

WATER DISTRIBUTION SYSTEMS

1. The Water Safety Committee will coordinate remedial action for environmental control, if any amount of environmental Legionella pneumophila is identified.

2. If quarterly environmental water testing is positive for Legionella species (but not L. pneumophila), additional water samples will be taken to see if L. pneumophila may be growing elsewhere.

3. If the results of the environmental validation are positive for L. pneumophila, the following will be promptly notified: Chief of Staff, the Associate Director for Patient Care Services, and the Facility Water Safety Committee. The Chief of Staff and the Associate Director for Patient Care Services are responsible for ensuring that clinicians involved in direct patient care are notified of the positive environmental results, including the species and serogroup detected (if appropriate), in order to implement heightened awareness for clinical testing for LD.

A. Mitigation Protocol

1) The mitigation protocol will be implemented in the following situations:

a) If the facility has any amount of Legionella pneumophila detected with environmental water testing.

b) If the facility has a history of epidemiologically-linked healthcare associated (HCA) Legionella disease (LD) or if the facility identified epidemiologically-linked HCA LD from clinical screening, then the mitigation protocol needs to be implemented to reduce the risk of exposure of patients to Legionella from the facility water distribution system.

2) Mitigation protocol options. There are a number of options for mitigation protocols to reduce Legionella in water systems. Facilities may consider the implementation of more than one (1) mitigation option in the Action Plan. Options for mitigation include, but are not limited to:

a. Thermal Eradication. This method, also referred to as superheat and flush, uses high water temperature to kill Legionella present in the water system. The procedure involves the temporary resetting of the hot water temperature to 160-170° Fahrenheit (F) or 71-77° Celsius (C) and the flushing of the system by selectively opening all valves for at least 30 minutes. Thermal eradication is temporary; Legionella species typically reappear in one (1) to three (3) months after the procedure. Note: Since there is significant risk for scalding at these water temperatures used for thermal eradication, extreme care must be taken to protect end users of the water distribution system.

b. Hyperchlorination. This method involves increasing the chlorine level, such that a free chlorine residual of at least two (2) milligrams (mg) per liter (L) is maintained throughout the system for at least two (2) hours (but not exceeding 24 hours). Chlorination of the water heater or tank to a concentration of 20 to 50 mg/L may be required to achieve this level of free chlorine residual. After the hyperchlorination procedure is complete, the system needs to be thoroughly flushed. Hyperchlorination results in temporary eradication of Legionella.

c. Point-of-Use Filters. Filters are attached at distal water sites, such as faucets and showers, to prevent exposure of patients to even low levels of Legionella in the water. This mitigation method may be of particular use in areas that treat high-risk patients.

B. Evaluate the Mitigation Effort

1) Upon completion of remediation, water samples will be promptly retested to determine if the remediation was successful at reducing Legionella pneumophila to undetectable levels.

2) If Legionella pneumophila is detected in the retested samples, a review of the remediation procedures will be done and further remediation and testing will be conducted to reduce Legionella pneumophila to undetectable levels.

3) A summary flowchart for interpretation of routine quarterly environmental water testing results can be found in Attachment I.

4) A written summation of remediation activities and findings is to be submitted to the facility Environment of Care Committee and Infection Control Committee.

ATTACHMENT B

DEFINITIONS

1. Anti-scald device. Anti-scald device is a temperature actuated appurtenance used in plumbing systems to reduce/stop water flow exceeding a defined temperature. Individual anti-scald devices must meet American Society of Sanitary Engineers (ASSE) 1062 Standard. Anti-scald devices may be add-on or integrated into plumbing fixtures or integrated into water tempering valves.

2. Biocide. For the purpose of this Directive, a biocide is a chemical agent or substance which can deter, inactivate, or kill microorganisms.

3. Chlorine. Chlorine is an EPA listed biocide chemical (oxidant) approved for use in the treatment of potable water to control/inactivate waterborne bacteria, viruses, and protozoa. In high concentrations, it can be used for the disinfection of water systems and their components.

4. Chlorine dioxide. Chlorine dioxide is an EPA listed biocide chemical (oxidant) approved for use in the treatment of potable water to control/inactivate waterborne bacteria, viruses, and protozoa.

5. Clinical testing. Clinical testing encompasses the spectrum of diagnostic modalities that are used to elucidate the cause of a disease process. In particular, for this Directive, they are specific for the diagnostic modalities used to determine the presence of LD. These clinical testing modalities include culture for Legionella species, Legionella pneumophila urinary antigen testing, serological testing using IgG and IgM antibodies with acute and convalescent serology (convalescent serology is obtained “after the fact” and can help confirm a diagnosis in retrospect), and nucleic acid antibody/molecular diagnostic testing. There is an expectation that appropriate clinical testing is done as standard practice by providers when caring for patients with a certain disease process.

6. Clinical Validation. Clinical validation is the process of determining if the primary engineering controls and any supplemental water treatment systems are successfully inhibiting Legionella growth in the potable water distribution system(s) by monitoring the occurrence of HCA LD. For the purpose of this Directive, clinical validation encompasses diagnostic testing of HCA pneumonia cases for LD when indicated and heightened awareness for diagnostic testing when Legionella is detected in environmental samples.

7. Community-associated Legionella disease (CA-LD). In general, CA-LD is a laboratory-confirmed case of Legionella disease in which the patient has not had contact with the healthcare setting in the 10 days prior to onset of illness.

8. Control measure. A control measure is any action or activity that can be used to prevent or eliminate a hazard or reduce the hazard to an acceptable level. [WHO, 2007].

9. Continual or Continuous. For the purposes of this Directive, continual or continuous refers to the almost uninterrupted monitoring and control of: water quality, incoming water pressure, biocide levels, and water temperatures. This can be achieved through the use of automated measurement/control devices, typically connected to the Building Automation System (BAS), at various locations such as water source equipment and throughout the water distribution system. Central recording of measurements is needed at least every 30 minutes and instantaneously during out-of-control limit (alarm) conditions. More frequent measurement recording for some or all parameters/locations may be required by the Facility Water Safety Committee or the State (or its delegated local water authority).

10. Corrective action. Corrective action is any action to be taken when the results of monitoring indicate that a primary or supplemental control is not within the established control limits.

11. Disinfection. Disinfection is an irreversible inactivation of microorganisms on a surface or in a system and the reduction of those microorganisms to non-hazardous levels. Low level chemical disinfection of potable water systems can be accomplished through the use of EPA listed biocides. High level disinfection for new installations or maintenance of piping, equipment, and components is conducted in accordance with the requirements of the International Plumbing Code (IPC 2009), American Water Works Association (AWWA C651-05), and VA Master Construction Specifications.

12. Distal. Distal means remote. In plumbing systems “distal” piping, equipment, or water outlets can be either physically or hydraulically remote, or in instances both, from a source point. NOTE: The term “distal water site” was used in previous VHA Legionella prevention policy to refer to points where the end user accesses the water; this term has been replaced by “outlet” in this Directive.

13. Emergency Remediation. Emergency Remediation is the process of implementing immediate, temporary actions to reduce the amount of Legionella in a water distribution system.

14. Engineering Control limit. An engineering control limit is a minimum and or maximum value at which a parameter must be maintained in order to prevent or eliminate a hazard or reduce the hazard to an acceptable level. For example, a minimum hot water temperature of 124 degrees Fahrenheit (°F) inhibits Legionella growth in building hot water systems.

15. Environmental Validation. For the purpose of this Directive, environmental validation is the process of testing the building’s potable water distribution system(s) to determine if engineering controls are successfully inhibiting growth of Legionella.

16. Flushing of Outlets. Flushing of outlets is the process of opening outlets such that hot and cold water flows out of the outlet for a specified period of time (specific duration varies with purpose and process). The purpose of routine flushing is to prevent stagnating conditions in pipes which could result in tempering of water temperature, dissipation of biocide, and establishment of favorable conditions for Legionella growth.

17. Healthcare-associated Legionella disease (HCA LD). HCA LD is a laboratory-confirmed case of Legionella disease that is epidemiologically-linked to the healthcare facility. HCA LD cases may be “definite” or “possible”. The definitions below for these classifications are based on information in the CDC 2003 guidelines for prevention of healthcare-associated pneumonia and the updated CDC Legionellosis Case Report form released in January, 2014. NOTE: Each case of LD should be assessed for linkage to the facility on a case-by-case basis taking into account any related factors (e.g., a change in definition during a LD outbreak, molecular matching of patient and environmental isolates).

A. Definite HCA LD. “Definite HCA LD” is a laboratory-confirmed case of Legionella disease with an inpatient stay that is equal to or greater than 10 days of continuous inpatient stay prior to onset of illness. (CDC Guidelines, 2003; CDC Legionellosis Case Report form, 2014)

B. Possible HCA LD.

1) “Possible HCA LD (inpatient)” is a laboratory-confirmed case of Legionella disease in which a patient has spent 2 to 9 days in a healthcare facility prior to onset of illness. (CDC Guidelines, 2003)

2) “Possible HCA LD (inpatient and outpatient)” is a laboratory-confirmed case of Legionella disease in which the patient had exposure to a healthcare facility for a portion of the 10 days prior to onset of illness. (CDC Legionellosis Case Report form, 2014)

18. Healthcare-associated Legionella Disease (HCA LD) Prevention Plan. The HCA LD Prevention Plan is the written plan required for every VHA building where patients, residents, or visitors stay overnight. The HCA LD Prevention Plan focuses on identification of risks and implementation of engineering measures for control of Legionella growth, monitoring of the control measures, validation that the measures are effective at suppressing Legionella growth, and implementation of corrective actions when indicated. The HCA LD Prevention Plan is to be reviewed at least annually for any updating.

19. Hyperchlorination. See “Shock chlorination”.

20. Immersion Bath. Immersion bath is a bath in which an individual’s entire body or a body part is submerged in water.

21. Legionella. Legionella is a Gram-negative bacterium that is naturally found in water and has been associated with building water distribution systems and cooling towers. Over 50 species and 70 serogroups have been identified.

22. Legionella Disease (LD). LD is the term used in this Directive for the disease traditionally known as “Legionnaires’ disease;” a type of pneumonia caused by pathogenic species of the bacterium, Legionella. Most, but not all, cases of disease are caused by the species Legionella pneumophila serogroup 1.

23. Legionellosis. Legionellosis refers to diseases (Legionnaires’ disease, Pontiac Fever) caused by pathogenic species of Legionella bacteria. Legionnaires’ disease is defined above (see “Legionella disease”). Pontiac fever is a milder respiratory infection and symptoms resolve without treatment.

24. Legionnaires’ Disease. See “Legionella disease.”

25. Mitigation. Mitigation is a process of implementing actions to reduce the amount of Legionella in a water distribution system (also called “remediation”).

26. Mixing Valve. Mixing valve is a generic reference to a class of water tempering devices. Mixing valves used for tempering hot water in potable water systems must meet the requirements of the International Plumbing Code (IPC 2009), American Society of Sanitary Engineers (ASSE 1016/1069/1070), and VA Master Construction Specifications.

27. Monitoring. Monitoring, for the purpose of this Directive, refers to the process of routinely checking water quality of incoming water (from municipal or central plant) and implementation of primary and any supplemental engineering controls to determine if the controls are within established minimum and maximum limits.

28. Monochloramine. Monochloramine is a type of chloramine. Chloramines are most commonly formed when ammonia is added to chlorine. An EPA listed biocide chemical (oxidant) approved for use in treatment of potable water to control/inactivate waterborne bacteria, viruses, and protozoa.

29. Outlet. Outlet is a point in the potable water distribution system where the individual (also known as the “end user”) accesses the water. Examples include faucets, showers, ice machines, and drinking fountains. NOTE: In previous VHA Legionella prevention Directives, the term “distal site” was used instead of “outlet.”

30. Oxidant residual. Oxidant residual is the amount of available oxidant present in the water system and at the outlet after demand has been satisfied. Required oxidant residuals in a water system are, in-part, determined by: water quality, water system conditions (piping system corrosion, water flow/turnover, etc.), presence of disinfection by-products, and type and quantity of microorganisms requiring inactivation.

31. Point-of-use filter. Point-of-use filter is a micropore filter specifically designed for use in preventing the passage of Legionella bacteria, other specific microorganisms, and particle contaminants present in water. Typically, these filters are fitted to water outlets or installed in water supply lines proximal to equipment (e.g., ice machines, drinking fountains).

32. Potable Water Distribution System. Potable water distribution system is a water distribution system (hot water and cold [unheated] water) within a building or structure primarily used for drinking, sanitation, food service, and personal hygiene meeting EPA and state drinking water standards.

33. Primary control measures. Primary control measure refers to the main or routine methods used to suppress Legionella growth in building potable water distribution systems. Primary control measures often used in building potable water distribution systems include at least one (1) of the following: appropriate water temperature(s) and treatment with biocide(s) (e.g. oxidizing agent).

34. Process flow diagram. Process flow diagram is a systematic representation of the sequence of steps or operations used in the production or manufacture of particular item [WHO, 2007].

35. Remediation. Remediation is the process of implementing actions to reduce the amount of Legionella in a water distribution system (also called “mitigation”).

36. Resident. Resident is defined here for the purpose of clarifying which buildings fall subject to this Directive. In the phrase “VHA buildings in which patients, residents or visitors stay overnight”, the term “resident” refers to Veterans who are under residential-type care such as provided at a Community Living Center or domiciliary.

37. Shock chlorination. Shock chlorination is the application of hypochlorite, usually in the form of a solution, to the water distribution system at higher than normal levels for remediation purposes.

38. Supplemental or Supplementary Water Treatment. A measure used in addition to routine (primary) control measures to inhibit the growth of Legionella in building water distribution systems.

39. Thermal eradication. Thermal eradication is the temporary resetting of the temperature in the hot water distribution system to 160°F - 170°F (71°C - 77°C) while continuously flushing each outlet in the system for at least 30 minutes (also known as “super heat and flush").

40. Validation. Validation is the process of obtaining evidence that a plan is effective. For purposes of this Directive, validation specifically refers to verifying that the primary and any supplemental engineering controls are effective at inhibiting the growth of Legionella in building potable water distribution systems. The two (2) validation methods used are environmental water testing for Legionella and clinical testing of pneumonia patients for Legionella.

41. Water distribution system. Water distribution system is a system used for the distribution of potable water (site and building) which includes all piping, water treatment, equipment, controls, fixtures, and components.

42. Water System Management Point. A specific position, device, fixture, or water distribution system component used for the monitoring of conditions or performance or the control of the system or its individual components.

ATTACHMENT C

HOT WATER TEMPERATURE RECORD

VA HEALTH CARE SYSTEM – FARGO

ATTACHMENT D

HOT WATER AT PATIENT CARE TAP TEMPERATURE RECORD

Choose random lavatory taps quarterly! Record archive period: 2 years.

(E)lectronic

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ATTACHMENT E

QUARTERLY SCALD GUARD INSPECTION

Comments/Recommendations

ATTACHMENT F

EYEWASH STATION CHECKLIST

EMERGENCY SHOWER INSPECTION FORM

ATTACHMENT H

SUMMARY FLOW CHART FOR INTERPRETATION OF ROUTINE QUARTERLY ENVIRONMENTAL WATER TESTING RESULTS IN THE ABSENCE OF HCA-LD

NEW ATTACHMENT I

SUMMARY FLOW CHART FOR CLINICAL VALIDATION

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